Provider Demographics
NPI:1780917930
Name:PETERSON MARKET LLC
Entity type:Organization
Organization Name:PETERSON MARKET LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-254-0761
Mailing Address - Street 1:1784 W 12600 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7025
Mailing Address - Country:US
Mailing Address - Phone:801-254-0809
Mailing Address - Fax:801-254-5892
Practice Address - Street 1:1784 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7025
Practice Address - Country:US
Practice Address - Phone:801-254-0809
Practice Address - Fax:801-254-5982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-04
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT863173217033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140532OtherPK
UT1780917930Medicaid